How can patients be appropriately screened for anesthesia when ambulatory surgery is planned?
In the ideal situation, on the day before surgery a patient having an ambulatory procedure would have the oppor-tunity to participate in a private conference with the anes-thesiologist who will be caring for him or her. Rapport and trust could be established, and history and physical assessment could be conducted. Furthermore, appropriate laboratory tests could be ordered and additional con-sultations, if deemed necessary, could be requested. Finally, information from old medical records could be obtained.
To avoid an additional trip for the patient and family, some facilities may substitute a screening telephone inter-view for a personal interview, conducted by either a nurse or an anesthesiologist several days before surgery. Pertinent medical history can be elicited, general and specific instruc-tions can be given, and reassurance offered to the patient. In this scenario, laboratory studies and additional compo-nents of the data base including an electrocardiogram (ECG) and radiographs, if necessary, are performed immediately before surgery. Previously established criteria will deter-mine the tests that must be obtained. Of course, on the day of surgery the anesthesiologist must still review all information with the patient, conduct the appropriate examination, and obtain informed consent.
The surgeon who schedules surgery must assume a large degree of responsibility for the medical evaluation of the patient. The surgeon is often the only physician to see the patient until the day of surgery. Besides conducting a thorough history and physical examination, the surgeon may also request medical consultation when appropriate.
To aid in the screening process, surgeons may also selec-tively order laboratory and other examinations according to written guidelines established by the medical facility. However, a mechanism should be in place for free commu-nication between the surgeon’s office and the facility so that appropriate action may be taken when abnormal laboratory values or other reports are received.
The anesthesiologist’s preoperative interview should be conducted in a relaxed, unhurried, and comprehensive manner both chronologically and geographically apart from the operating room. It is highly improper to conduct the preanesthesia interview and examination with the patient stripped of clothing and strapped to the operative room table. At this moment, the patient’s anxiety level may be extraordinarily high. Therefore, the patient may neglect to communicate essential information that may have an impact on either general medical care or intraoperative anesthetic management. Under these circumstances, it is truly impos-sible to obtain informed consent for anesthesia, which is a moral as well as a legal necessity. Additionally, with the surgeon and nurses waiting and instrumentation prepared, the pressure on the anesthesiologist to proceed with anes-thesia may be intense.
The anesthesiologist should not fail to question patients firmly regarding the use of illicit drugs. In one patient population, one quarter of the subjects were found to have positive urine findings for commonly abused substances. Depending on the drug involved, modifications in patient management including cancellation of surgery might be well advised. Additionally, users of illicit drugs may have diminished capability or interest in complying with post-operative instructions.